BACKGROUND: Chest computed tomographic angiograms (CTAs) are frequently ordered for evaluation of suspected pulmonary embolism (PE) in the emergency department, but non-PE findings are often noted. Our objective was to determine the prevalence and management implications of incidental findings on chest CTAs ordered to assess for PE. METHODS: In a cross-sectional study, we reviewed 589 pulmonary CTAs that were ordered in the emergency department of a tertiary care hospital. We measured the prevalence of PE and placed other findings into the following 3 categories: (1) findings that provided potential alternative explanations for acute symptoms, (2) incidental findings that required clinical or radiologic follow-up, and (3) other findings that required less urgent or no follow-up. We reviewed all newly diagnosed pulmonary nodules and significant thoracic adenopathy and determined standard recommended clinical follow-up. RESULTS: Pulmonary embolism was found in 55 of 589 CTAs (9%). A total of 195 CTAs (33%) had findings that supported alternative diagnoses. A total of 141 patients (24%) had a new incidental finding that required diagnostic follow-up, including 73 patients (13%) with a new pulmonary nodule and 51 patients (9%) with new adenopathy. Using current clinical guidelines, follow-up computed tomography or another procedure would be recommended for 96% of patients with new incidental pulmonary nodules. CONCLUSIONS: The CTAs that are ordered in the emergency department are more than twice as likely to find an incidental pulmonary nodule or adenopathy than a PE. Systematic approaches should be developed to help primary care physicians contend with a growing number of clinically relevant incidental radiologic findings.